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Department of Health and Human ServicesPrescription Drug Abuse Advisory Committee
March 10, 2017
PRESCRIPTION DRUG ABUSE ADVISORY COMMITTEE MEETING DECEMBER 9, 2016
Alan Dellapenna, Head, Injury and Violence Prevention
Branch, Chronic Disease and Injury Section, Division of
Public Health
Sarah Potter, Chief of Community Wellness, Prevention
and Health Integration, Division of Mental Health/DD/SAS
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Welcome and Introductions of Attendees
SR/FS
PRESCRIPTION DRUG ABUSE ADVISORY COMMITTEE MEETING DECEMBER 9, 2016
• SPF-Rx and SPF-SIG
–Sarah Potter, Chief of Community Wellness, Prevention and
Health Integration, Division of Mental Health/DD/SAS
• MAT and Opioid STR/Cures Act
–DeDe Severino, Interim Section Manager, Addictions and
Management Operations, Division of Mental Health/DD/SAS
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Update: Division of MH/DD/SAS – SAMSHA Grants (Ongoing and Pending applications)
SR/FS
NC Opioid State Targeted Response Grant Application (SAMHSA)
DeDe Severino, Interim Section Manager, Addictions and Management Operations, Division of Mental Health/DD/SAS
NC Opioid STR
•Section 1003 of the 21st Century Cures Act established an account for a total of $1 billion ($500 million in FY 2017 and $500 million in FY 2018) for prevention, treatment and recovery services, related programming and activities.
•The funding opportunity can be described as a hybrid – combination of block and discretionary grants, as there is a specific allocation amount for each state/territory, only SSAs are eligible applicants, but states must apply.
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•Amount available to NC: $15,586,724 for FFY17, and an additional $15,586,724 for FFY18. •Amounts for states were derived from a formula
based on unmet need for opioid use disorder treatment and drug poisoning deaths.
▪80% of the funds must be spent for OUD treatment and recovery support services;
▪5% limit on administrative/infrastructure costs to administer the grant;
▪Remaining 15% can be used for prevention activities
•Application was submitted 02.17.17
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NC Opioid STR
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NC Opioid STR
•Much interest in this initiative, input and feedback was received from over 35 groups, individuals and sister agencies within DHHS
•Topical areas included in the application:1. Marketing – Improve Public Perception2. Training – Improve Workforce Development and
Retention3. Treatment – Improve Patient Engagement,
Retention and Outcomes4. Accessibility – Improve Engagement, Retention
and Outcomes5. Prevention – Increase Awareness and Reduce
Use/Misuse
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NC Opioid STR
•Topical areas, cont.,6. Controlled Substances Reporting System (CSRS) –
Prevent Use and Misuse, Intervene Through Integration and Analytics
7. ECHO – Improve Workforce and Accessibility to MAT in Rural Areas
8. Augment/Enhance Other Current Strategies
•States expect to be notified of funding in mid to late April
•Copy of the grant is located at https://www.ncdhhs.gov/divisions/mhddsas/grants
•Questions – [email protected]
PRESCRIPTION DRUG ABUSE ADVISORY COMMITTEE MEETING: March 10, 2017
OCME: Fentanyl and Its Analogues
Dr. Ruth E. Winecker, Chief Toxicologist, Division of Public Health
9SR/FS
HEROIN AND FENTANYL Historical Perspective and a Look to the Future
Ruth E. Winecker, Ph.D. F-ABFT
Chief Toxicologist, NC-OCME
Alison Miller, MA
Epidemiologist, NC-OCME
TOP FIVE DRUGS CAUSING DEATH 2000-2015
YEAR 1st 2nd 3rd 4th 5th
2000 Methadone Cocaine Morphine Oxycodone Ethanol
2001 Methadone Cocaine Oxycodone Morphine Heroin
2002 Methadone Cocaine Oxycodone Morphine Heroin
2003 Methadone Cocaine Morphine Oxycodone Heroin
2004 Methadone Cocaine Morphine Oxycodone Fentanyl
2005 Cocaine Methadone Hydrocodone Oxycodone Fentanyl
2006 Methadone Cocaine Oxycodone Fentanyl Morphine
2007 Methadone Cocaine Oxycodone Fentanyl Morphine
2008 Methadone Oxycodone Cocaine Fentanyl Morphine
2009 Methadone Oxycodone Cocaine Fentanyl Morphine
2010 Methadone Oxycodone Cocaine Fentanyl Morphine
2011 Methadone Oxycodone Cocaine Oxymorphone Fentanyl
2012 Cocaine Oxycodone Methadone Heroin Fentanyl
2013 Oxycodone Methadone Heroin Cocaine Oxymorphone
2014 Heroin Cocaine Oxycodone Fentanyl Methadone
2015 Heroin Cocaine Oxycodone Fentanyl Oxymorphone
3973 4158 4170 4167
4509
4724 4808 4722
4490
4749
4494
4125
0
1000
2000
3000
4000
5000
6000
2010 2011 2012 2013 2014 2015
Nu
mb
er
of
De
ath
s
Year
Accidental Deaths Natural Deaths
ACCIDENTAL VS. NATURAL DEATHS 2000-2015
3036 3116 3119 3155 3210 3248
937 1042 1051 1012
1299 1476
0
500
1000
1500
2000
2500
3000
3500
4000
4500
5000
2010 2011 2012 2013 2014 2015
Other Accidents Poisoning
23% 25% 25% 24% 28%
31%
ACCIDENTAL DEATHS 2000-2015
108 130 112 95 165 241 352
1.1
1.4 1.2
1.0
1.7
2.4
0.0
0.5
1.0
1.5
2.0
2.5
3.0
0
50
100
150
200
250
300
350
400
2010 2011 2012 2013 2014 2015 2016
Number Rate per 100,000
Fentanyl
44 78 164 188 279 399 397
0.5 0.8
1.7 1.9
2.8
4.0
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0
4.5
0
50
100
150
200
250
300
350
400
450
2010 2011 2012 2013 2014 2015 2016
Number Rate per 100,000
Heroin
0 0 1 2 29 71 119
0.3
0.7
0.0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0
20
40
60
80
100
120
140
2010 2011 2012 2013 2014 2015 2016
Number Rate per 100,000
Both
TOTAL CASES POSITIVE
114
174 197
306
396
526
157
134 126
181
245
425
0 0 0 9
38
195
0
100
200
300
400
500
600
2011 2012 2013 2014 2015 2016*
Cas
es P
osi
tive
Year
Heroin
Fentanyl
Fentanyl Analogues**
DEATHS ATTRIBUTED TO FENTANYL ANALOGUES IN NORTH CAROLINA, 2010 – 2016*
7
29
2 1 0 0 0 0
11
1
77
1 0
10
20
30
40
50
60
70
80
90
2010 2011 2012 2013 2014 2015 2016
Acetyl Fentanyl
Butrylfentanyl
Fluorofentanyl
Furanylfentanyl
Multiple Analogues
TEST VOLUME OPIOIDS CLASS
Year 2011 2012
2013 2014 2015 2016
Mitragynine 0 0 2 29 27 95
Loperamide 0 0 6 25 46 68
Buprenorphine 95 101 46 104 98 68
Methadone 659 669 501 370 341 325
U-4770 0 0 0 0 0 137
Tramadol 75 79 93 103 111 103
Fentanyl 382 337 282 416 522 937
Fentanyl Analogues 0 0 0 23 87 412
Opiates* 1338 1456 1504 1832 1959 2005
Total Results (all tests) 43,423 42,543 43,300 44,269 48,410 54,948
HOW DID WE GET HERE?
• Fentanyl and analogues are just the latest in a long string of
compounds that have been introduced to the illicit drug market in
the last 10 years.
• Commonly referred to as “research chemicals,” synthetic drug
chemists have rediscovered old drugs from patents or modified
existing drugs to change their structure so that they are exempt
from current controlled substances scheduling.
• The swiftness with which these new drugs are developed is
staggering and challenges the abilities of forensic laboratories.
• Today, all drug classes are represented in the new compounds
being sold online and in more traditional drug supply chains.
SOME COMMON NPS DRUGS SEEN BY NC-OCME
• Synthetic Cannabinoids: commonly referred to as Spice or K2, these compounds mimic the
effects of marijuana
• Cathinones/Piperazines: commonly referred to as bath salts, plant food and Flakka; these
compounds mimic the effects of methamphetamine and MDMA (Ecstasy/Molly)
• Anxiolytics: all NPS in this class are classical benzodiazepines these include delorazepam,
etizolam
• Hallucinogens: mimic the effects of classic hallucinogen-dissociative drugs. Examples
include PCP and ketamine analogues as well as the NBOMe series
• Synthetic Opioids: This group of compounds is designed to mimic the effects of morphine,
oxycodone, heroin and other common prescription opiates/opioids. Some are similar in
chemical structure to existing compounds (e.g., fentanyl) while others are more novel (e.g.,
U-47700)
SCREENING TECHNIQUE CHANGES
• 2000- added a fentanyl immunoassay
• 2008- added an oxymorphone specific immunoassay to screen for Opana overdoses
• 2010-shelved immunoassays as too limited/expensive and developed a LC-ion trap-
MS screening technique to detect 10 opioids, 9 benzodiazepines, cocaine metabolite,
gabapentin/pregabalin
• 2016-added six designer opioids to the LC-ion trap-MS screen
• 2017-plan to add 22 new designer fentanyl analogues to the screen
NEW DRUGS DETECTED BY TRADITIONAL SCREENING METHODS
• The Organic Bases screen has been employed by the laboratory for 30 years
• Unlike the LC-ion trap-MS screen this test does not screen for a specific set number
of drugs but instead will detect any basic organic compound that is present at
sufficient concentration to register a response on the detectors (GC-NPD and GCMS)
• Most new drugs detected then require development and validation of a quantitative
confirmation assay
Drug Class 2011 2012 2013 2014 2015 2016
Fentanyl Analogues 0 0 0 1 3 5
Other Opioids 0 0 2 0 0 1
Designer Benzodiazepines 0 0 0 0 1 2
Cathinones (“bath salts”) 5 9 1 1 1 5
THE CHALLENGE
• September 2015
• Death of a 20 year old female
• Traditional toxicology tested negative except for
4-ANPP , also known as despropionyl fentanyl
• November 2015
• Obtained powder from death scene and analyzed
• Large peak without a database match
• Tentatively identified as furanylfentanyl
• March 2016
• Certified reference material available
• Method development and validation
• June 2016
• Toxicology report certified
NOT SO FAST
259 273 287 231
245
Fentanyl
Butyryl-
259
Valeryl-
273
Hexanyl-
287
Acetyl-
231
Identification of some new fentalogs
Fentanyl
THF-F
CONCLUSIONS
• Current screening techniques are capable of detecting >400 drugs, poisons and
chemicals.
• The NC-OCME toxicology lab is well positioned to identify new synthetic opioids as
they appear in the decedent population.
• Challenges include procuring certified reference materials and development and
validation of confirmation testing in a timely basis.
• Increases in the total number of overdose deaths and number of drugs detected per
case overwhelms the lab’s resources.
• Data requests can be accomplished on the OCME website.
• http://www.ocme.dhhs.nc.gov/annreport/index.shtml
PRESCRIPTION DRUG ABUSE ADVISORY COMMITTEE MEETING: March 10, 2017
Spotlight: Drug Take Back and Law Enforcement Assisted Diversion
Donnie Varnell, Judy Billings, Melissia Larson
10SR/FS
PDAAC
LAW ENFORCEMENT
SPOTLIGHT
Investigator Donnie Varnell
Dare County Sheriff’s Office
336-338-1507
PDAAC (MARCH 17TH)
LE SPOTLIGHT
Enforcement Trends
SEP & Naloxone
Strategies
Operation Medicine Drop
Counties with Drop Boxes October 2016
SBI Purchase of Drop Boxes
2017 Counties with Drop Boxes
Collection From LEAs By Year
Collection from LEAs-Dosage Units
CHALLENGES
•Obtaining RE-OCCURRING Funding from Legislature
•Education
•Manpower
PRESCRIPTION DRUG ABUSE ADVISORY COMMITTEE MEETING: March 10, 2017
Learn, Explore, and Clarify: Health insurers and opioids
John Stancil, NC Division of Medical Assistance (Moderator)
Dr. Anuradha Rao-Patel, NC Blue Cross Blue Shield
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21PROPRIETARY & CONFIDENTIAL® Marks of the Blue Cross and Blue Shield Association. U10404, 2/16
Anuradha Rao-Patel, MD, CPC
LEARN, EXPLORE, AND CLARIFY: HEALTH
INSURERS AND OPIOIDS
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AGENDA
1. Introductions and Background
2. BCBSNC Current Processes
3. Future and Ongoing
Considerations
4. Open Faucet, Mirror, and
Sandbox Analogies
5. Discussion and Questions
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BCBSNC CURRENT PROCESSES
1.Pharmacy
2.Care Management
3.Provider Outreach
4.Prevention of Fraud and
Diversion
5.Other
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FUTURE AND ONGOING CONSIDERATIONS
1.Collaborative Relationships
2.Adherence
3.Reduction of waste and
fraud
4.CDC guidelines
5.Education
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Open Faucets
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Sandboxes and Mirrors
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THANK YOU FOR YOUR TIME!
PRESCRIPTION DRUG ABUSE ADVISORY COMMITTEE MEETING JUNE 17, 2016 28
PDAAC Workgroup Time
Workgroup Name DHHS Facilitators Meeting Room
Prevention and Public Awareness,
Group A: Community
Nidhi Sachdeva
Sarah Potter
Pine Room
(Building 1 – 5505, 1st
Floor)Call Option: 919-431-2020
Prevention and Public Awareness,
Group B: Law enforcement
Melinda Pankratz
Donnie Varnell
Reaves Room
(Building 1 – 5505, 1st
Floor)
Call Option: 1-641-715-3680Participant code: 131286#
Intervention and Treatment Smith Worth
Dede Severino
Cardinal Room B (yonder)
Professional Training and
Coordination
Anna Stein
Sara McEwen
Alex Asbun
Cardinal Room A (Here)
Core Data and Surveillance Scott Proescholdbell
Anna Perry
Sparrow Room
(same floor, down hall)
RETURN at
12:05PM
BREAK and Transition!
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PRESCRIPTION DRUG ABUSE ADVISORY COMMITTEE MEETING DECEMBER 9, 2016
• Scott Proescholdbell, Epidemiologist, Injury and Violence
Prevention Branch, NC Division of Public Health
• PDAAC Website: https://sites.google.com/view/ncpdaac
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Announcements and News
PRESCRIPTION DRUG ABUSE ADVISORY COMMITTEE MEETING DECEMBER 9, 2016
Nidhi Sachdeva, Injury Prevention Consultant, Injury and
Violence Prevention Branch, NC Division of Public Health
• 2017 Opioid Misuse and Overdose Prevention Summit
–www.OpioidPreventionSummit.org
–June 27-28, 2017, at McKimmon’s Center in Raleigh
–REGISTER!
–Call for vendors and sponsors
• THANK YOU!!
(Please return your name badges, take food, and travel safely!)
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Wrap Up and Thank you!
